Inpatient Hospice Survey Readiness: Documentation & Compliance Essentials

Hospices that offer general inpatient (GIP) or respite care—either directly or through contractual arrangements—are subject to additional scrutiny during regulatory surveys. Ensuring documentation is complete, policies are up to date, and facility details are transparent is critical to demonstrating compliance and maintaining uninterrupted service delivery.

Below is a breakdown of what surveyors will expect when evaluating your inpatient hospice operations.

Inpatient Hospice Services: What Surveyors Will Review

Surveyors will assess where and how your agency delivers inpatient care. This includes whether care is provided directly within a hospice-owned facility or through a contractual agreement with another healthcare provider.

Inpatient Care Documentation

For facilities that provide direct inpatient hospice care, be prepared to present:

• Current inpatient census with:

  • Level of care: GIP or respite

  • Admission date

  • Primary diagnosis

  • Reason for admission

• Log of the last 30 days of inpatient admissions, including:

  • Admission and discharge dates

  • Reason for admission

  • Diagnoses at admission

This information helps surveyors determine medical necessity and appropriate service level classification.

Nursing Staff & Facility Operations

Survey teams will examine staff availability and facility operations to ensure consistent and qualified care delivery.

Documents to Have Ready:

• Nursing staff schedules (licensed and registered) for the past 30 days

• Visitor policy outlining current access regulations

• Emergency water source information (a verbal explanation is sufficient)

• Up-to-date facility floor plan

• Mealtime schedules and dining room locations

• Medication administration practices:

  • Times of administration

  • Locations of med carts or locked storage

• List of Interdisciplinary Group (IDG) personnel, including:

  • Roles

  • Locations

  • Contact numbers

Restraint & Seclusion Records

Agencies must show transparency in how they manage behavioral safety. Surveyors will request:

• Log of any patients placed in restraints or seclusion over the past 12 months

• Policies and procedures related to restraint and seclusion use
  This ensures adherence to patient rights and trauma-informed care practices.

Electronic Health Record (EHR) Access

Surveyors will need full access to all inpatient residents’ medical records, regardless of location. Important considerations include:

• Ensure no sections of the medical record are withheld, even if they reside outside the conference room environment.

• Provide clear instructions or live support to help surveyors navigate your EHR system effectively.

If the entrance interview did not take place at the inpatient location, confirm that all relevant records and facility information were still made available.

Additional Facility-Level Requirements

Surveyors may also request:

• Addresses of all locations where inpatient services are rendered

• Written agreements with facilities if care is provided under arrangement

• Patient care protocols, including emergency preparedness within the inpatient setting

Make sure all facility-related details are accurate, recent, and reflect the most current operational conditions.

Conclusion: Inpatient Survey Success Starts with Preparation

General inpatient and respite care services are a cornerstone of quality hospice delivery—but they come with rigorous compliance responsibilities. Ensuring your agency has all inpatient documentation, staff schedules, policies, and electronic records in order can make the difference between a seamless survey and compliance challenges.

Keep this checklist updated and conduct regular mock surveys to stay ahead of regulatory expectations.

Links:
Hospice Conditions of Participation – 42 CFR Part 418 (Including GIP & Respite Requirements)
CMS State Operations Manual – Appendix M (Hospice Survey Guidance) Includes survey procedures for inpatient hospice, facility review, GIP/respite documentation, staffing, EHR access, and contracts.
CMS Hospice Care Levels Definitions (GIP, Respite, CHC, RHC)
Medicare Benefit Policy Manual – Chapter 9: Coverage of Hospice Services Includes requirements for inpatient levels of care, medical necessity documentation, staffing, and facility conditions.